Varicocele is a leading reversible cause of male infertility, often associated with impaired spermatogenesis, reduced testicular function, and increased sperm DNA fragmentation. Microscopic varicocelectomy is the gold standard for treatment, but early predictors of postoperative improvement remain limited. Shear Wave Elastography (SWE), a non-invasive imaging modality measuring tissue stiffness, and the Sperm DNA Fragmentation Index (DFI) have shown potential as predictive tools. Hence we aimed to assess whether preoperative SWE values can predict post-varicocelectomy improvements in semen parameters and sperm DNA integrity, and to explore their role in guiding surgical decision-making.

A prospective study was conducted on 102 infertile men diagnosed with clinically palpable varicocele and scheduled for microscopic subinguinal varicocelectomy. SWE-derived testicular stiffness (in m/s and kPa) and volume were measured preoperatively and six months postoperatively. Semen analysis, including sperm count and motility, was performed at both time points. Sperm DNA fragmentation was evaluated using the Sperm Chromatin Structure Assay (SCSA) at baseline, 3 months, and 6 months post-surgery, with results expressed as DFI. P value of <0.05 was considered statistically significant.

Preoperative SWE values ranged from 1.3 to 2.0 m/s (5–12 kPa), with the majority of patients falling into the moderate stiffness range, suggestive of functional stress without irreversible damage. Postoperative SWE showed a significant reduction in stiffness and a corresponding increase in testicular volume. Mean baseline sperm count was 20.6 million/mL, which increased significantly to 28 million/mL at 6 months postoperatively. Progressive motility improved from 24% to 44.3%, reflecting a 20.3% absolute increase. DFI decreased markedly from 27 ± 11% preoperatively to 19 ± 5% at 3 months and 13 ± 4% at 6 months postoperatively. Patients with preoperative SWV values between 1.3–1.6 m/s (5–7.5 kPa) demonstrated the greatest improvements in both semen parameters and DFI. Those with SWV >2.0 m/s (>12 kPa) showed minimal change, indicating potential irreversible testicular fibrosis or atrophy.

Preoperative Shear Wave Elastography provides valuable insight into testicular health and can predict functional recovery following microscopic varicocelectomy. SWE values between 1.3–1.6 m/s (5–7.5 kPa) are associated with optimal postoperative improvements in sperm quality and DNA integrity.